Severe acute malnutrition (SAM)

E40/E41/E42/E43

• Description
• Complicated SAM
• Uncomplicated SAM
• Referral

DESCRIPTION

Diagnostic criteria for SAM in children aged 6-60 months (any one of the following):

Where a suitable measuring device is not available the following less sensitive findings would also indicate the need to manage as severe acute malnutrition:

• Severe underweight
  • WHZ < -3 (usually clinically reflective of marasmus) where no other explanation is present, and/or
  • clinically severe wasting (usually clinically reflective of marasmus - thin arms, thin legs, “old man” appearance, baggy pants folds around buttocks, wasted buttocks).
• Nutritional oedema* supported by findings of skin changes, fine pale sparse hair, enlarged smooth soft liver, moon face.

Exception

Babies who were premature and are growing parallel to or better than the z-score lines, should not be classified as failure to thrive or not growing well.

COMPLICATED SAM

E40/E41/E42/E43

DESCRIPTION

Any child with SAM who has any ONE of the following features:

• < 6 months of age or weighs < 4 kg.
• Pitting oedema.
• Refusing feeds or is not eating well.
• Any of the danger signs listed below.

Danger Signs

• dehydration
• hypoglycaemia
• vomiting
• hypothermia
• respiratory distress (including fast breathing)
• convulsions
• not able to feed
• shock
• lethargy (not alert)
• jaundice
• weeping skin lesions
• bleeding

All children with complicated SAM are at risk of complications or death.
Refer urgently!
Stabilise before referral.

Initiate treatment while waiting for transport to hospital.

GENERAL MEASURES

• Keep the child warm.
• Test for and prevent hypoglycaemia in all children.

If the child is able to swallow:

• If breastfed: ask the mother to breastfeed the child, or give expressed breastmilk.
• If not breastfed: give a 30–50 mL of a stabilising feed (F-75) or a breastmilk substitute before the child is referred.
• If no F-75 or breastmilk substitute is available, give 30–50 mL of sugar water. To make sugar water: Dissolve 4 level teaspoons of sugar (20 g) in a 200 mL cup of clean water.
• Repeat 2 hourly until the child reaches hospital.

If the child is not able to swallow:

• Insert a nasogastric tube and check the position of the tube.
• Give 50 mL of breastmilk, F-75, breastmilk substitute or sugar water by nasogastric tube (as above).

Repeat 2 hourly until the child reaches hospital.

If blood sugar < 3 mmol/L treat with:

• 10% Glucose:
  • Nasogastric tube: 10 mL/kg.
  • Intravenous line: 2 mL/kg.

CAUTION
In malnutrition, if IV fluids are required for severe dehydration/shock, give sodium chloride 0.9%, 10 mL/kg/hour and monitor for volume overload. Once stable continue with ORS orally or by nasogastric tube.

MEDICINE TREATMENT

Note: Signs of infection such as fever are usually absent. Treat infection while awaiting transfer.

If there are no danger signs, give1st dose while arranging referral to hospital:

• Amoxicillin, oral, 45 mg/kg as a single dose. See paediatric dosing tool.

If the child has any danger signs:

• Ceftriaxone, IM, 80 mg/kg/dose immediately as a single dose and refer. See paediatric dosing tool.
  • Do not inject more than 1 g at one injection site.

CAUTION: USE OF CEFTRIAXONE IN NEONATES AND CHILDREN

• If SUSPECTING SERIOUS BACTERIAL INFECTION in neonate, give ceftriaxone, even if jaundiced.
• Avoid giving calcium-containing IV fluids (e.g. Ringer Lactate) together with ceftriaxone:
  • If ≤ 28 days old, avoid calcium-containing IV fluids for 48 hours after ceftriaxone administered
  • If > 28 days old, ceftriaxone and calcium-containing IV fluids may be given sequentially provided the giving set is flushed thoroughly with sodium chloride 0.9% before and after.
  • Preferably administer IV fluids without calcium contents.
• Always include the dose and route of administration of ceftriaxone in the referral letter.

Give an additional dose of Vitamin A :

• Vitamin A (retinol), oral.

UNCOMPLICATED SAM

E43

DESCRIPTION

Children with SAM who meet the following criteria:

• The child is > 6 months of age and weight > 4 kg, and
• There is no pitting oedema, an
• The child is alert (not lethargic), and
• The child has a good appetite and is feeding well, and
• The child does not have any danger signs or severe classification (and does not require referral for another reason).

All cases require careful assessment for possible TB or HIV.

GENERAL MEASURES

• Provide RTUF and/or other nutritional supplements according to supplementation guidelines.
• Counsel according to IMCI guidelines.
• Regular follow-up to ensure that the child gains weight and remains well.
• Discharge with supplementation, once the following criteria are met:
  • WHZ (weight-for-height z-score): > -2 WHZ for two consecutive visits at least one month apart and/or
  • MUAC: > 11.5cm (preferably at 12 cm, if MUAC used alone).
• Follow patients for at least 6 months to ensure sustained growth.

MEDICINE TREATMENT

Do not repeat if child has received these during inpatient stay:

Give an additional dose of Vitamin A :

• Vitamin A (retinol), oral.

• Multivitamin, oral, daily.

Empiric treatment for worms:

• Mebendazole, oral.
  • Children 1–2 years: 100 mg 12 hourly for 3 days.
  • Children > 2–5 years: 500 mg as a single dose.

OR

• Albendazole, oral, single dose.
  • Children 1–2 years: 200 mg as a single dose.
  • Children ≥ 2 years and adults: 400 mg as a single dose.

LoEII [7]

REFERRAL

• When regular nutritional supplements (e.g. RTUF) cannot be provided and follow-up on an ambulatory (outpatient) basis is not possible.
• The child develops pitting oedema or any of the danger signs (see above).
• Failure to gain weight despite provision of nutritional supplements.